NEW HIRE TDA OPT

VCU Tax-Deferred Annuity (TDA) Auto-Enrollment Program
NEW HIRE TDA OPT-OUT FORM*
(for new-hire start date of January 1, 2008 or later)
➊ PARTICIPANT INFORMATION
V-ID # (contact your department’s Personnel Administrator for your V-ID #)
Last Name
Birth Date: MM
/ DD / YYYY
First Name
M.I
Street Address (and Apartment #, if applicable) or P. O. Box #
City
State
Zip Code + 4
 OPT-OUT ELECTION
[ ] I have received information about the Tax-Deferred Annuity (TDA) Program and, by
checking here, I do not wish to make any contributions to the TDA at this time, but
reserve the right to contribute at a later time according to TDA plan provisions.
 SIGNATURE
I have read and understand the materials describing the TDA program. I understand that
my election to opt out of participating in the TDA auto-enrollment program will remain in
effect until I elect to contribute to a TDA by completing a Salary Reduction Agreement (SRA)
and vendor enrollment form(s), as applicable. I further understand it is my responsibility to
ensure that my election is properly implemented (by reviewing my payroll statements on
eServices/VCU Self Service) and to notify VCU Human Resources at (804) 828-0740 if I
believe there has been an error.
Moreover, I understand that if I fail to notify VCU Human Resources of an error, I will be
deemed to have accepted participation in the TDA auto-enrollment program at a contribution
level of $20 each pay period.
Signature:
Date:
Name (print):
Please complete and return this form to:
VCU Human Resources
ATTN: Payroll Services
P. O. Box 842511
Richmond, VA 23284-2511
Questions? Contact VCU Benefits at [email protected] or (804) 827-1723.
* Must be completed within 60 days of hire date.
Revised January 2015 (logo only)
Created December 2007